#10: When $2.50 is too much

A note for all of the patients that go home untreated

There is a price attached to almost every decision in medicine here, and it is rarely abstract. It is counted in cash, in livestock, in phone calls to relatives, and sometimes in the quiet act of walking away. Lately, money has felt like the invisible vital sign in every room—always present, always shaping outcomes.

Over the past weeks, we have seen patient after patient whose care hinged not on diagnosis or skill, but on what they could afford in that moment. A man came in with a broken femur after a motorcycle accident. He wasn’t even the one driving—the driver had large cargo on the back of the motorcycle that fell and shattered his leg. He needed a traction splint and a reduction. He could not pay for either. He left. We assume that if he could not afford some treatment, he will either never walk again or walk with a severe limp for the rest of his life. It was incredibly hard to watch him go, knowing how completely his life may have been altered by that single moment. I’ve had friends back home who broke their femurs and made full recoveries—not because their injuries were less severe, but because the healthcare system they lived in made treatment possible.

Around the same time, we had a man present with Ludwig’s angina, a rapidly progressive and often fatal infection. I only have a photo of his X-ray, but I’ll include an infographic later to explain what the condition is and why it’s so dangerous. As he was leaving—because he could not afford the top-of-the-line antibiotics he required—Hillary told me that three out of four previous patients who presented here with Ludwig’s angina later died. I haven’t heard anything about him since. Without strong antibiotics, it is likely that he will die.

This week, we also treated a man with an umbilical hernia. Albertine has operated on him five times for the same condition. He has liver failure from alcoholism, which causes fluid to accumulate in his abdomen, distending his stomach and worsening the hernia again and again. It is an incredibly painful condition. On February 6th, we operated using a new, more expensive mesh than he had received previously, placing it on the wall of the abdominal cavity. By the morning of February 7th, his stomach was already severely distended, and we could not even drain all of the fluid. By the morning of February 8th, it was clear that if we did nothing, the hernia would return—and quickly. Hillary was extraordinary with this patient. We have already subsidized the surgery significantly and minimized costs everywhere possible, but that also means we cannot provide the most advanced treatments. Hillary would love to place an abdominal drain to limit the distension, but the patient cannot afford it. We are currently trying to help him obtain an abdominal compression sleeve. Most likely, the painful hernia will come back for the sixth time. Unless the alcoholism is addressed, his condition will not improve in the long term.

One day this week, two different mothers came in with fetal tachycardia, where the fetus’s heart rate is dangerously fast. These patients need medication urgently—both their lives and their babies’ lives are at risk. Both mothers left the hospital without treatment. They could not afford it.

Along the same vein, we lost a baby this week. I used a bag-valve mask on this newborn for around an hour. The baby had meconium aspiration and necrotizing enterocolitis. The mother also has malaria, so it is possible the baby was born—by emergency caesarean section—already infected with malaria. There was truly very little we could do. What makes it especially painful is knowing that this baby likely would have survived in the United States. With access to a vacuum extractor to allow for vaginal birth, an intubation machine, or even a CPAP machine, it is very possible that we could have successfully cared for this baby. Even Albertine is limited in the care we provide because of the services we are able to provide. We don't even have an AED machine!

Because of realities like these, there is a way that patients learn to work the financial system of care here. Many come in asking only for a “scan.” They repeat the word over and over, emphasizing that they do not want to consult with a doctor. This allows them to avoid the 10,000 UGX doctor consultation fee—about $2.50. Of course, the hospital staff cares deeply about patients, so we make an effort to examine the results of every ultrasound and X-ray regardless. When we find something concerning or distressing, we call the patient back and try to convince them to spend a little more money to get the medication, treatment, or surgery they need. Then one of three things usually happens. Least often, they immediately say yes and pay. Sometimes they leave to find money—calling family members or selling cattle or livestock. And just as often, they simply never come back. They leave without getting the care they need. It is an incredibly hard problem. Do you charge a patient for the doctor's consultation when they can only afford a scan? Doctors deserve to be paid for their work. On average, doctors here make about 2 million UGX per month—roughly $7,000 USD per year. It is a highly respected position in this society (for those who believe in medicine), but it is not well paid. And yet, I see the generosity of this facility every day behind the scenes. Hillary and the doctors are always looking for the cheapest effective options. They subsidize patients they know cannot pay, try less expensive medications and labs first, and stretch resources as far as possible. Kindness truly abounds here—but that doesn’t mean patients aren’t forced to work the system to survive. Sometimes it is deeply frustrating to have a critical patient who insists they only want an X-ray when you know exactly what they need and cannot get it to them.

In the middle of all of this, I had my own first medical “emergency”—or at least, the hospital staff made it feel like one. I felt off last weekend: chills, a headache, then a sore throat. When I checked my temperature Saturday morning, I had a low-grade fever. I didn’t want to make much of it—I’ve been overworking myself generally, so getting sick wasn’t surprising. But the fever kept rising. At its highest, it reached 38.6°C (101.5°F), and the doctors became concerned. They wanted to do a blood test and a malaria test as soon as possible. I told them I didn’t want blood tests or anything extreme and that I would just go sleep and check in later. They won that argument quickly. About ten minutes later, my blood was being drawn, and Hillary was using words like sepsis. I actually started to get scared. What did I have? Was it serious? Did I need to tell my family? The labs showed a bacterial infection. I was given an injection to lower the fever and put on several medications—a broad-spectrum antibiotic, menthol tablets, and an NSAID. I was completely out for one day. Then I looked in my throat and saw white spots. Strep throat. That’s it. All of the testing and treatment would have cost me 38,000 UGX—about $10 USD—but Hillary would not let me pay. Don’t worry. His kindness will be repaid many times over, both in cash and in kind.

This experience only strengthened my desire to help in more concrete ways. I want to revitalize the donor page for Albertine and eventually build a new website—one that will outlive me long after I leave. I plan to train someone on staff to manage it, and I’m happy to keep working on it for the rest of my life. It would be incredible to allow people back in the U.S. to support specific patients, medications, surgeries, or operations. Hillary does not want care to be completely free—he believes every patient should take some active financial role in their care, and I understand that. But he does want a surplus fund to support the poorest patients who come in with the most critical conditions. A caesarean section here costs about $171 USD. I’ve watched mothers desperately call relatives across the country to pay for a surgery that saved their life. I know I can help with this.  I just need to reach out to my family, friends, churches I have attended in the past, etc. I also have technical skills that are genuinely useful here—data analysis, spreadsheets, cost-benefit analysis, and even just basic computer troubleshooting skills. I am the only person at the hospital, perhaps besides Hillary, who can type relatively fast. These are small things, but they matter.

All of our patient forms say, “We treat. God heals.” I really love that. Hillary lives it. He knows people throughout the town and not only remembers their medical histories but tells them what they need to be doing for their own health. He does none of this for money. He is simply kind and deeply committed. His patient interactions are long and thoughtful—he asks countless questions, looks for underlying causes, and welcomes discussion with nurses, doctors, and even me. He moves slowly, deliberately, and with real empathy. Watching him work is one of the best parts of being here.

And finally—sorry I haven’t posted in a while. I’ve been trying to do more around the hospital while still adjusting to life here. I’m getting more confident, learning where I can step in and help, and picking up new Runyoro phrases every day. I’m learning so much that my brain hurts by the end of the day, in the best way. I’m incredibly grateful to be here—stretched, overwhelmed, and having a lot of fun. To another week of learning and adventures ahead. More posts soon.